PDHRA/PHA Provider Recruitment Form

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PDHRA/PHA Provider Recruitment Form

* First Name:		* Last Name:		Title:
Practice Or Organization Name (if applicable) :

Please list all professional license nubmers, applicable state, and the license expiration date:

License Type:

License No:

Licensed State:

License Expiration Date:

Additional License Information:

Are all the listed license(s) current and unrestricted?: Yes No Please Note: LHI verifies all professional license information

*Street Address :
Suite, PO Box:

*City:

*State:

* Zipcode:

*Primary Phone:

Alternate Phone:

Mobile Phone:

Fax:

* E-mail Address:

* Verify E-mail Address:

Do you have a military background?

Yes No

Are you currently on active duty?

Yes No

Are you current reservist?

Yes No

How did you hear about LHI?

Conference/Event

Brochure

Website

Referral

other

Additional Comments or Questions: